Cycle 1
Health 2023-08-24 · Fire 2023-08-24
7 health deficiencies
Top issue: Administration (2 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Westlake, OH
Lutheran Home
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
2116 Dover Center Rd, Westlake, OH
(440) 871-0090
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
87
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.55
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.44
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.55
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.55
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.00
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
4.32
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.27
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
4.61
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
21%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,598
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.81
Composite VBP score used to determine payment impact.
Payment multiplier
1.0026
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.13
Baseline 20.67% · Performance 19.05% · Measure score 5.13 · Achievement 5.13 · Improvement 3.94
Healthcare-associated infections
7.72
Baseline 6.38% · Performance 5.53% · Measure score 7.72 · Achievement 7.72 · Improvement 5.65
Total nurse turnover
2.71
Baseline 71.97% · Performance 56.85% · Measure score 2.71 · Achievement 1.67 · Improvement 2.71
Adjusted total nurse staffing
3.96
Baseline 4.72 hours · Performance 4.20 hours · Measure score 3.96 · Achievement 3.96 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.77% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 135 · Observed rate 12.59% · Lower 95% interval 8.23% |
| Discharge to community | 56.46% |
50.57%
5.9 pts better
|
No Different than the National Rate · Eligible stays 121 · Observed rate 50.41% · Lower 95% interval 47.84% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 84 · Denominator 84 |
| Falls with major injury | 1.19% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 84 |
| Discharge self-care score | 64.29% |
53.69%
10.6 pts better
|
Numerator 36 · Denominator 56 |
| Discharge mobility score | 30.36% |
50.94%
20.6 pts worse
|
Numerator 17 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 1.19% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 84 · Adjusted rate 1.42% |
| Healthcare-associated infections requiring hospitalization | 5.53% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 1.37% · Lower 95% interval 3.23% |
| Staff COVID-19 vaccination coverage | 29.71% |
8.2%
21.5 pts better
|
Numerator 71 · Denominator 239 |
| Staff flu vaccination coverage | 78.33% |
42%
36.3 pts better
|
Numerator 188 · Denominator 240 |
| Discharge function score | 44.64% |
56.45%
11.8 pts worse
|
Numerator 25 · Denominator 56 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 37 · Denominator 37 |
| Transfer of health information to patient | 90% |
96.28%
6.3 pts worse
|
Numerator 27 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 9.3% |
25.2%
15.9 pts worse
|
Numerator 4 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.1 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
92.4%
7.3 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.8% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.3%
0.3 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.2% · Q3 4.1% · Q4 4.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
26.1%
24.3 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 1.4% · Q4 1.7% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 9.3% |
6.2%
3.1 pts worse
|
5.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 8.3% · Q3 12.1% · Q4 7.5% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.9% |
25.4%
1.5 pts worse
|
19.6%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 24.6% · Q3 31.0% · Q4 27.8% · 4Q avg 26.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.3% |
11.5%
0.2 pts better
|
16.7%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 12.0% · Q3 12.0% · Q4 10.6% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.4% |
7.7%
14.7 pts worse
|
16.3%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.9% |
6.2%
3.7 pts worse
|
14.9%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 8.6% · Q3 14.8% · Q4 9.8% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
0.5%
0.5 pts worse
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.4% · Q4 1.6% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.0% |
21.7%
11.3 pts worse
|
19.8%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.9% · Q2 31.7% · Q3 29.8% · Q4 35.9% · 4Q avg 33.0% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
3.7%
1.3 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 6.5% · Q3 7.2% · Q4 4.7% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
78.1%
21 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 99.3% · Q3 99.3% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
12.5%
4.6 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 7.4% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.3% |
75.6%
23.7 pts better
|
79.7%
19.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
25.1%
0.6 pts better
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 22.2% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-16 · Fire 2020-01-16
1 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-11-29 · Fire 2018-11-29
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-08-24
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-10-12
F · Potential for more than minimal harm
2023-08-24
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-10-12
F · Potential for more than minimal harm
2023-08-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-08-24
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-08-24
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-08-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-08-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-08-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-08-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-08-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-08-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-08-24
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-08-24
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-08-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-12
F · Potential for more than minimal harm
2020-01-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-21
E · Potential for more than minimal harm
2020-01-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-02-21
E · Potential for more than minimal harm
2020-01-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-02-21
F · Potential for more than minimal harm
2018-11-29
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2019-01-30
F · Potential for more than minimal harm
2018-11-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-01-30
F · Potential for more than minimal harm
2018-11-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-01-30
F · Potential for more than minimal harm
2018-11-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-01-30
F · Potential for more than minimal harm
2018-11-29
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2019-01-30
F · Potential for more than minimal harm
2018-11-29
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-01-30
F · Potential for more than minimal harm
2018-11-29
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2019-01-30
F · Potential for more than minimal harm
2018-11-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-01-30
E · Potential for more than minimal harm
2018-11-29
K227 · Egress Deficiencies
Fire Safety
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Corrected 2019-01-30
E · Potential for more than minimal harm
2018-11-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-01-30
E · Potential for more than minimal harm
2018-11-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-01-30
E · Potential for more than minimal harm
2018-11-29
K524 · Services Deficiencies
Fire Safety
Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly.
Corrected 2019-01-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-24
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-12-08
D · Potential for more than minimal harm
2023-08-24
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-24
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-10-12
C · Minimal harm
2023-08-24
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-10-12
C · Minimal harm
2023-08-24
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-10-12
F · Potential for more than minimal harm
2020-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-02-21
F · Potential for more than minimal harm
2018-11-29
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-01-30
D · Potential for more than minimal harm
2018-11-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-01-30
D · Potential for more than minimal harm
2018-11-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-01-30
D · Potential for more than minimal harm
2018-11-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-01-30
D · Potential for more than minimal harm
2018-11-29
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-01-30
D · Potential for more than minimal harm
2018-11-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-01-30
D · Potential for more than minimal harm
2018-11-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-01-30
Penalties and ownership
What sits behind the stars
Ownership
Anderson, Todd
Corporate Director · Individual
Bowersox, James
Corporate Director · Individual
Bowersox, James
Corporate Officer · Individual
Bowersox, James
W-2 Managing Employee · Individual
Brueshaber, Larry
Corporate Director · Individual
Fowerbaugh, Andrew
Corporate Director · Individual
Hildal, Robyn
Corporate Director · Individual
Kahle, Thomas
Corporate Director · Individual
Klawitter, Chris
W-2 Managing Employee · Individual
Mcdonald, Kenneth
W-2 Managing Employee · Individual
Mcquinn, Scott
Corporate Director · Individual
Mcquinn, Scott
Corporate Officer · Individual
Mcquinn, Scott
W-2 Managing Employee · Individual
Miniaci, Anthony
Contracted Managing Employee · Individual
Molnar, Dave
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Life Care Center Of Westlake
Westlake, OH
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Rae-Ann Westlake
Westlake, OH
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Huntington Woods Care & Rehab Center
Westlake, OH
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
Jump out